As the old adage goes, if you want to lose weight, simply eat less and exercise more. Right? Actually, not so fast.
While it's true that obesity at its core is an imbalance between calorie intake and expenditure, to suggest that what the World Health Organization has dubbed a global epidemic boils down to a lack of willpower is rather reductive.
In reality, obesity is, according to the Centers for Disease Control, a complex chronic disease influenced by many factors. Yes, lack of physical activity and unhealthy eating patterns are among them, but so are genetics (believed to account for over 50 percent of obesity), lack of sleep, stress, access to healthy food and affordable health care and even policy decisions.
Lacking willpower is but one of several preconceived notions when it comes to weight management that research has shown can actually lead to adverse health outcomes, including lower quality care, delayed medical attention and even additional weight gain.
We spoke with Kimberly Gallien, a licensed social worker at Houston Methodist's Center for Weight Loss and Bariatric Surgery, about how our collective understanding of obesity has evolved — from lack of willpower to a complex, multifactor disease — and how we can start to recognize and counter potentially harmful misconceptions.
Myth 1: Obesity is primarily caused by a lack of willpower and self-control
"When it comes to weight loss and weight management in people with obesity, what we've come to understand is that it's not always a lack of nutrition education, lack of willpower, overeating or laziness that contributes to carrying more weight," says Gallien. "I remind people every day when I'm meeting with them for psychiatric evaluations that it could also be that you're not getting enough nutrition."
While that may come as a surprise, research shows that lower rates of obesity and diabetes are found in areas with increased access to healthy foods. On the other hand, food deserts — areas that have limited access to affordable and nutritious food — have a positive correlation with obesity rates.
"Why would I pay $15 for one salad when I can get two cheeseburgers for $5?" asks Gallien. "It's this access to healthy food — including cost — that drives a lot of the decisions and choices we make, and it can ultimately make people feel like they can't get a handle on their health."
Besides access to healthy foods, there are factors that researchers know influence the likelihood of someone developing obesity, according to the CDC.
Long-term stress can affect how your body regulates and balances hunger urges, the federal agency says. Cortisol is one such hormone that can increase your appetite and promote cravings for food. That's why weight gain is a hallmark symptom of Cushing syndrome — a rare condition in which your body has too much cortisol.
Even the conditions in which people live, work and play can influence a person's propensity for developing obesity. Community design, school environments, safe housing, transportation and economic stability all have a role to play in the choices we make, says the CDC.
"Many times it's not just about what we put in our bodies," she adds. "There are so many factors that we look at beyond that and what's on the scale that go into how you feel and where you are in your journey."
Weight loss, according to Gallien, is not so much willpower as what she refers to as "planning power."
"When you start to ask yourself, 'Why?' when making food choices, the answer will tell you what your next step should be, and this is what I like to explore with patients," she says. "If you're invited out to dinner, let's look ahead at the menu and plan what you're going to eat."
Happy hour, watching television and even going to the grocery store are a few examples of food-related behaviors that Gallien advocates her patients create action plans around.
Myth 2: People with obesity are less active
It's a common misconception that people with obesity are "lazy" and should "get off the couch."
In reality, regardless of how much weight they carry, an overwhelming majority of Americans do not meet the physical activity guidelines set by the U.S. Department of Health and Human Services to maintain good health: Only 26 percent of men, 19 percent of women and 20 percent of adolescents meet that standard.
Therefore, nearly every American could stand to benefit from more exercise — not just those who happen to carry more weight.
Moreover, a lack of physical activity is also influenced by the environment in which people find themselves. Walkable neighborhoods and access to recreational facilities are known social determinants of health, which have been shown to have a greater influence on health than genetics or access to health care services, per the CDC.
"When dealing with a metabolic disease like obesity, we have to look at the whole person, not just what's on the scale, and realize it's often skewed by things beyond our control," says Gallien. "That said, it's important we feel like we have control over our lives and know that we can take that control back."
"Rather than focusing on what we cannot control, we can instead focus on what we can — getting enough sleep, creating an eating schedule that works for you and checking off boxes in other areas of life that allows us to feel productive," she adds.
Myth 3: BMI is a good determination of healthy weight
"What I tell people is BMI goes out the window once you're born," says Gallien. "That metric was created for people and by people whose body type no longer exists."
BMI or body mass index is a value based on the height and weight of a person and was originally devised as a metric for European men between 1830 and 1850. One major pitfall with BMI is that it does not differentiate between muscle mass and fat mass. It's most commonly why athletes — high in muscle mass — get labeled as overweight or obese using the BMI scale.
Not all fat is created equal, either. The fat that's stored just beneath your skin — the kind that you can pinch between your fingers — is called subcutaneous fat and is generally considered less harmful that visceral fat, the fat behind your abdominal muscles that can't be seen. Higher amounts of visceral fat are associated with an increased risk of cardiovascular disease, dementia, asthma and certain cancers.
Where and what type of fat you tend to gain will depend on your genetics, age, gender and ethnicity, among other factors. Therefore, it's also why BMI can often be biased against women and people of non-European origin, given the scale was created using only one race and gender.
"BMI is not the be-all and end-all metric most people think it is," says Gallien. "BMI is an imperfect measuring tool, which is why I appreciate the body composition assessments we use here at the Center for Weight Loss because it can give you a better overview of what your body actually is made of, including muscle mass, water weight and different fat percentages."
(Related: Are Body Composition Scales Accurate?)
Myth 4: Obesity is a well-understood disease
Only in 2013 did the American Medical Association officially recognize obesity as a disease — and not without controversy. The association actually made the decision against the advice of its public health and science committee, which cited the existing limitations of BMI and questioned whether obesity fit within the definition of a disease or a condition.
Because obesity has many causes, factors and influences, the consensus on what exactly causes it to develop has yet to be determined. Yes, nutrition and exercise play a role, but so does genetics, which includes appetite, fat storage and metabolism. Moreover, weight is not a sole indicator of health.
This confusion can also bleed into health care settings as weight bias, the judgments that health care providers sometimes can make without even realizing it, says Gallien. Weight stigma is a result of that, she says.
"I had a client tell me a doctor told her when you get to a certain weight, then maybe you'll get married," she says. "As healthcare professionals, we have to be careful to reduce our own unconscious and conscious biases surrounding weight and obesity."
Studies show that medical providers can exhibit both implicit bias — a prejudice that's present but not consciously held or recognized — and explicit bias, meaning a conscious prejudice. Moreover, these biases and stigmas have been shown to delay getting care, both among people with obesity and those who are not classified as such.
"Because I work in the Center for Weight Loss, I'm hyper aware of weight bias, even in doctors' offices, where I might see the chairs are all fairly small — for someone with a larger body, they'll have to figure out where they're going to be able to sit," she says. "Many patients mention that this simple task of where to sit can be a barrier to living their life."
"When they're flying on a plane, they can get the extender, but they have to ask for it," she adds. "These are things that might not come to mind for some people, but for those who experience it, it can be quite limiting for them in life and can take quite an emotional toll."
Myth 5: Weight loss is mostly about losing weight
For many people with obesity, weight loss is part of their health journey, but not all of their journey, according to Gallien.
"Think of a time when you've ever tried to improve your health or make any changes in life, and you started out doing the same thing every day, but every day you were rendered different results," says Gallien. "That's what weight loss is like."
"I could eat a salad every day, and yet still see a different number on the scale either up or down," she continues. "It's because weight loss is not linear, and the journey is not about calories in, calories out."
It's important to view your health journey in its entirety, she says, not just by a diagnosis or number.
How well did you sleep? What's your mood like today? Did you move your body in a way that felt good? These are all questions Gallien says that are just as important as what you weighed or what you ate.
"Expect setbacks but remember that successful weight management is not about willpower — it's about planning power, focusing on the areas where you can control and create a plan that works for you."
